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This is a Test

It is ONLY a Test
A 16 y/o girl just passed out after receiving her
penicillin shot for strep throat (doesnt swallow
pills). Which of the following will be most useful
to know in treating her:

A Her Blood Pressure
B Her Glucose level
C Her Heart Rate
D Your Heart Rate

Which of the following is the safest and most
efficient route to administer epinephrine in
an allergy emergency:

A IV
B Sub Q
C IM
D PR
Which of the following potential allergens do
not generally cross-react:

A. COX-2 inhibitors & Ibuprofen
B. Filberts & Pecans
C. Peanuts & Tofurky
D. Lobster & Shrimp
A first year PEM fellow attending conference
developed a sudden onset of urticaria, lip
swelling and DIB. The etiology is most
likely a reaction to:

A smelling someone elses lunch
B a spider bite
C another billing talk by Dr Linzer
When advising parents/patients on how to
administer an epi-pen you should tell
them to:

A. hold it against the triceps and squeeze the
trigger
B. stab it into the anterior thigh
C. hold it against the lateral thigh and push
Which is NOT a clinical presentation of
anaphylaxis:

A. Vomiting and Diarrhea
B. Syncope
C. Altered Mental Status
D. Itchy Tongue
In counseling a 50kg 15 year old after a severe
episode of anaphylaxis to a bee sting your best
advice is that if they get stung again they first
should take

A. (2) 25mg diphenhydramine capsules PO
B. (5) tsp diphenhydramine elixer PO
C. .5mg epinephrine SQ
D. 60mg prednisone PO
Which of the following treatments has been shown
to decrease the incidence of biphasic reactions:

A. Corticosteroids
B. Epinephrine
C. Diphenhydramine
D. Ranitidine
ANAPHYLAXIS
Michael Greenwald, MD
Pediatric Emergency Medicine
Emory University
Childrens Healthcare of Atlanta @ Egleston
Objectives
Recognize patients with, or at risk for,
anaphylactic reaction
Understand the immunologic basis for
anaphylactic reactions
Know the interventions appropriate for
anaphylactic reactions
Know the appropriate medical follow-up
Historical Background
ana- backward phylaxis- protection
Portier and Richet: reactions in dogs exposed to
sea anenome toxin
First documented case: Egyptian pharoah 2640
B.C. dies after wasp sting
Defining Anaphylaxis
Acute
Systemic
Allergic (i.e. requires prior exposure)
Special Features of Anaphylaxis
Spectrum of severity
Variety of manifestations
Uniphasic, biphasic or protracted
Epidemiology
Top triggers: then
penicillin
insect venom
food


Top triggers: now
Latex (27%)
Food (25%)
Drugs (16%)
Venoms (15%)
Anaphylaxis Epidemiology
84,000 cases/year in US
1% fatal
Kids > adults
Food Allergy
under 4 y/o: 6-8%
After 10 y/o: 2%
29,000 cases food induced anaphylaxis/year
2000 hospitalizations
150 deaths; high association with asthma, peanut/tree nut allergy
Peanuts are # 1 and increasing in Western nations
Hypersensitivity review: Gell and
Coombs Classification
Type I - Anaphylactic
Type II - Cytotoxic
Type III - Immune Complex
Type IV - Delayed Type
Type I - Anaphylactic
Immediate: Exposure to reaction < 30minutes
Late Phase: Exposure to reaction: 2-12 hours
Exposure to reaction: <30minutes
Effector cell: IgE
Antigen: pollens, foods, drugs, venoms
Mediators: histamine, leukotrienes
Manifestations: anaphylaxis, allergic rhinitis, allergic asthma, urticaria
Type II - Cytotoxic
Exposure to reaction: variable (minutes to
hours)
Effector cell: IgG, IgM
Target: Red blood cells, Lung tissue
Mediators: Complement
Examples: Immune hemolytic anemia, Rh
hemolytic disease, Goodpasture syndrome
Type III - Immune Complexes
Exposure to reaction: 6 - 21 days
Effector cell: Antigen with Antibody
Target: Vascular endothelium
Mediators: Complement, Anaphylatoxin
Symptoms: fever, urticaria, arthralgia, arthritis,
lymphadenopathy
Examples: Serum sickness, PSGN
Type IV - Delayed Type
Exposure to reaction: 24-48 hours
Effector cell: Lymphocytes
Antigen: Chemicals, Mycobacterium tuberculosis
Mediators: Lymphokines
Examples: Contact dermatitis, Tuberculin skin reactions
Anaphylaxis and Her Cousin
Anaphylaxis
IgE mediated
IgG - immune complex mediated

Anaphylactoid
direct stimulation of mast cells and basophils
unknown mechanism
IgE - mediated Anaphylaxis
Prior exposure required
Allergen-IgE binding induces release of mediators:
histamine
prostaglandins
platelet activating factor
tryptase
IgG -immune complex mediated
complement activated by immune complexes or
other agents
Tissue antigens - RBC, WBC, Plts
Serum proteins - Immunoglobulin, cryoprecipitin
anaphylatoxins: C3a, C5a
Anaphylactoid : Direct stimulation
direct stimulation of mast cells and basophils
unknown mechanism - suspect high osmolarity
examples: radiocontrast media (not assoc w/
iodine, shellfish allergy), mannitol, opiates,
curare, dextran, chemotherapeutic agents
Unexplained Anaphylaxis
Unknown mechanism:
ASA and other NSAIDS
preservatives
exercise
mastocytosis
cholinergic urticaria with anaphylaxis
progesterone: catamenial anaphylaxis
Unexplained Anaphylaxis
Idiopathic anaphylaxis: unknown trigger
up to 37% of all reactions
clinically indistinguishable from other forms
particularly stressful to patients
Epidemiology
Patients at risk:
Does atopic history matter?
Who gets the worst reactions?
Latex
Allergens
Drugs
Foods
Venoms
Latex
Defining Drug Reactions
Predictable Drug Reactions
80% of all adverse effects
dose dependent
related to known pharmacological effect
Unpredictable Drug reactions
not dose dependent
occurs in susceptible individuals
unrelated to known pharmacological effect
Drugs
Antimicrobials
Penicillin: 2 potential groups of allergens
Major determinant: Benzyl penicilloyl
Minor determinants: penicillin, penicilloate, penilloate,
penicilloylamine
Cephalosporins
Sulfonamides
Drugs
NSAIDS
bronchospasm in 2-10% of asthmatics
unknown mechanism: IgE and mast cells not involved
Drugs
Macromolecules:
protamine
insulin
IVIG
2 recognized mechanisms
IgA deficiency high risk
slow infusion and pretreat
Drugs
Chemotherapeutic agents: L-Asparaginase
Vaccinations: MMR?
Immunotherapy
17 fatalities reported 1985-1989 (10 million shots given
annually)
precautions for medical facility:
observe 20 minute
medications and airway support available
Drugs
Radiocontrast media
mast cell degranulation from anaphlatoxins of
complement cascade
older agents: Hypaque, Renigrafin
mild reaction in 5%, severe - 1/1000, death - 1/10-
40,000 exposures
risk factors:
atopic/asthma history
adult
Foods
Tree nuts: 1% Americans (3 million) allergic
Legumes: 25-35% also allergic to tree nuts
Shellfish
Fish
Milk
Eggs
Food additives: sulfites
Foods That May Contain Peanut Oil
Arachis oil (peanut oil)
Baked Goods and mixes
Biscuits, cookies, pastries
Candy
Cereals
Chocolate
Emulsifiers, flavorings
Ethnic foods: African, Chinese,
Mexican, Thai, Vietnamese
Ice Cream
Margarine
Milk formula
Satay Sauce (thai sauce)
Soft drinks
Soups
Sunflower seeds
Vegetable fats and oils
Venoms/Antivenins
5 major stinging insects in the US:
honeybees
wasps
yellow jackets
hornets
fire ants
Rabies and snake antivenin
Latex

incidence low, except for risk groups:
>1000 episodes and 15 deaths attributed
surgical and dental procedures highest risk
RAST testing available
Exercise-induced
Variety of forms of exercise
not heat alone
not associated with atopy/asthma
strong genetic predisposition
histamine and parasympathetic tone,
sympathetic tone
Exercise-induced
4 phases:
Prodrome: fatigue, warmth, pruritis & erythema
Early: urticaria, angioedema
Fully established: (30- 4 hours) stridor, choking,
N/V/D, syncope, hypotension
Late: fatigue, warmth, headache, lasts up to 72 hours
Exercise-induced
Diagnosis: may resemble asthma or cholinergic
urticaria
very unpredictable; some associated with foods
Management:
recognize early signs and rest
avoid hot, humid weather
exercise with a partner
Symptoms
Manifestations in the shock organs
skin, respiratory tract, gastrointestinal tract,
cardiovascular system
Why there?
rich in mast cells
sensitive to effects of mast cell mediators
exposure to high concentrations of antigen
Skin
Early signs:
Flushing, feeling warm
Erythema
Pruritis
Urticaria
Angioedema
Pallor
Respiratory
Upper airway
Nose & eyes: pruritis and watery discharge, sneezing
Lips & tongue: swelling and pruritis
Larynx & epiglottis: edema with hoarseness, dysphonia
to asphyxia
Bronchi: bronchospasm with wheezing,
decreased aeration, to apnea, asphyxia
Gastrointestinal
not only with food triggers

crampy abdominal pain, nausea, vomiting, watery
diarrhea, gastointestinal bleeding, fecal
incontinence
Cardiovascular
Intravascular volume depletion
Direct effects on the heart:
arrythmias
reduced contractility
reduced coronary blood flow
Early: dizziness and confusion
May progress to: syncope, seizures, loss of
consciousness shock, cardiac arrest
Other symptoms of anaphylaxis
Neurologic: HA, Mental Status changes
Uterine contraction
Urinary incontinence
Anxiety, Feeling of impending doom
Natural history of anaphylactic
reactions
Onset of reaction after exposure: seconds to
several hours. Depends on
patients sensitivity
dose of allergen
route of entry
Biphasic reactions (1 28 hrs)
5-23% in adults; 6% in kids
Food, venom, medication induced anaphylaxis
Second reaction may be worse
Making the correct diagnosis
May look just like:
Asthma exacerbation
Croup or foreign body aspiration
Cardiogenic syncope
food poisoning or gastroenteritis
Vasovagal vs. Anaphylaxis
Vasovagal
pallor
diaphoresis
bradycardia or NSR
Anaphylaxis
tachycardia
flushing
urticaria/pruritis/ bronchospasm
Differential Diagnosis
Related Diseases
Serum Sickness
Systemic Mastosytosis
Urticaria Pigmentosa
Unique presentations
MI, PE, CVA, Seizure, asphyxia, hypoglycemia
Making the correct diagnosis
Detailed history as close to the event as possible
All foods in prior 6-12 hours
Consider all ingredients
Look for likely suspects: e.g. legumes
Write it and keep it
Prick skin tests: Best Screening test
high false positives; very low false negatives
may require food challenge

Less common lab tests
histamine vs. tryptase level
transient
Tryptase NOT elevated in food-induced anaphylaxis
RAST: measures specific IgE,
less sensitive than skin prick
Useful in pt.s who cant d/c antihistamines or w/skin condition
Coombs test - Type II
complement levels - Type III
patch testing - Type IV

Treatment
Prevention, education and observation
Early intervention
Medications
Managing a difficult airway
Early intervention: epinephrine
Injection Kits: Epipen, Ana-kit, Anaguard
When to give?
How to administer?
location: SC vs IM, site of stinger
dosing
Inhaled epinephrine
Precautions: Beta-blockers and Tricyclics
Medical adjuncts
Antihistamines
Use in all cases
H1 blockers: route and type
H2 blockers
Steroids
Use in all significant cases
PO (liquid), IM or IV: 2mg/kg (max 60 mg?)
Prevents delayed reactions
Bronchodilators & aminophylline
Supportive treatment and airway
issues
Hypotension may not respond to epinephrine
Aggressive use of IVF + Trendelenberg, vasopressors if
necessary
MAST trousers, glucagon and naloxone also reported
helpful
Laryngeal edema and angioedema of the face pose
critical airway challenges
Prevention
Food allergies:
Avoid entire food group if sensitive to one member (unless
proven safe)
Canned fish (heated) may be tolerated if tested under
controlled setting
Beware baked goods
Learn ingredients, pseudonyms and synonyms
Drug allergies:
desensitization: a temporary measure
premedicate and observe closely
Prevention, education and
observation
Venom allergies:
Dont entice the insects: sights and smells
Who gets venom immunotherapy?
Educate all caretakers
4 hour observation/ hospital observation if not
resolving rapidly
Which of the following is the safest and most
efficient route to administer epinephrine in an
allergy emergency:
A IV
B Sub Q
C IM
D PR
Syncope after shot
A 16 y/o girl just passed out after receiving her penicillin
shot for strep throat (doesnt swallow pills). Which of
the following will be most useful to know in treating her:

A Her Blood Pressure
B Her Glucose level
C Her Heart Rate
D Your Heart Rate

A first year PEM fellow attending conference
developed a sudden onset of urticaria, lip swelling
and DIB. The etiology is most likely a reaction to:

A smelling someone elses lunch
B a spider bite
C another billing talk by Dr Linzer
Allergen Families
Which of the following potential allergens do not
generally cross-react:

A. COX-2 inhibitors & Ibuprofen
B. Filberts & Pecans
C. Peanuts & Tofurky
D. Lobster & Shrimp
Using the Epi-Pen
When advising parents/patients on how to
administer an epipen you should tell them to:

A. hold it against the triceps and squeeze the
trigger
B. stab it into the anterior thigh
C. hold it against the lateral thigh and push
Presentations of Anaphylaxis
Which is NOT a clinical presentation of anaphylaxis:

A. Vomiting and Diarrhea
B. Syncope
C. Altered Mental Status
D. Itchy Tongue
E. None of the above
First line therapy
In counseling a 50kg 15 year old after a severe episode of
anaphylaxis to a bee sting your best advice is that if they
get stung again they first should take

A. (2) 25mg diphenhydramine capsules PO
B. (5) tsp diphenhydramine elixer PO
C. .5mg epinephrine SQ
D. 60mg prednisone PO
Which of the following treatments has been shown
to decrease the incidence of biphasic reactions:

A. Corticosteroids
B. Epinephrine
C. Diphenhydramine
D. Ranitidine
Summary:
Various mechanisms and presentations

May resemble common illnesses

Early recognition and treatment

Prevention is critical

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